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Full text of "Diseases Of The Nose Throat And Ear"

CHAPTER 35
TRACHEOSTOMY

There has been confusion between the terms tracheotomy and tracheostorny
which have in the past been used indiscriminately. Etymologically, tracheo-
tomy means making an opening into the trachea, while tracheostorny means
converting this opening to a stoma on the skin surface. Thus in the operation
of tracheostorny the actual opening of the trachea is tracheotomy. Tracheo-
stomy is one of the earliest operations ever described, and there is evidence
that it was performed by the Egyptians in Biblical times.

FUNCTION OF A TRACHEOSTOMY

A tracheostorny is performed to relieve an upper airway obstruction, to
facilitate bronchial toilet, to decrease dead space, to assist ventilation and as
an elective procedure in head and neck surgery.

Relief of Upper Airway Obstruction. An obstruction of the airway may occur
with dramatic suddenness as in the case of an inhaled, impacted foreign body
in the larynx. There may be a moderate urgency in acute inflammatory lesions,
such as acute epiglottitis, acute laryngotracheobronchitis or the acute laryngeal
oedema of the child burned by drinking from a boiling kettle. There may be the
slowly progressive respiratory embarrassment, for example in laryngeal cancer
which is being treated by irradiation.

Bronchial Toilet. A basic failure in respiration may require that the patient
receive assistance by removing his bronchial secretions. This may occur in a
central„ depression of the respiratory centre from coma, cerebrovascular
accidents, head injury or drug overdosage; or there may be neurological
problems such as poliomyelitis, cervical cord lesions, polyneuritis, myasthenia
gravis or tetanus.

Dead Space. Dead space may be reduced by 30-50 per cent thereby improving
respiratory efficiency, and thus assisting the patient who has to rely on his own
respiratory efforts rather than on assisted ventilation.
Assisted Ventilation. Should assisted ventilation be required this may be
started with an endotracheal tube for 72 hours. While there is still no absolute
proof that intubation which has been prolonged for more than 72 hours
causes laryngotracheal damage, it is probably safer to do a tracheostomy at
this stage and to continue the intermittent positive-pressure ventilation by this
means. Should the patient not have improved sufficiently in the first 3 days
with an endotracheal tube, it becomes difficult to assess how much longer the
tube must be worn, and each 24 hours increases the risk of serious laryngo-
tracheal damage.

Elective Operation. In nearly all cases of major head and neck surgery it is
safer to perform an elective tracheostomy, not only to maintain the airway
but to protect it against haemorrhage.

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